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Conservative restoration of the worn dentition - the anatomically driven

direct approach (ADA)

Article  in  The international journal of esthetic dentistry · January 2018

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 CLINICAL RESEARCH

Conservative restoration of the worn

dentition – the anatomically driven
direct approach (ADA)
Rui Negrão, DMD
Private Practice in Porto, Espinho, and Lisbon, Portugal
Postgraduate in Esthetic Dentistry, ISCS Egas Moniz, Lisbon, Portugal

Jorge André Cardoso, DMD

Private Practice in Espinho and Porto, Portugal
MClinDent Prosthodontics, King’s College London
Honorary Clinical Teacher, King’s College London

Nuno Braz de Oliveira, DMD

Private Practice in Lisbon, Portugal
Postgraduate in Orthodontics, NYU, New York

Paulo Julio Almeida, DMD, PhD

Private Practice in Porto, Portugal
Assistant Professor, Prosthodontics, Porto University, Portugal

Teresa Taveira, DMD

Private Practice in Espinho, Portugal
MSc, Aesthetic Dentistry, King’s College London

Oleg Blashkiv, CDT

Private Practice in Porto, Portugal
Lviv University, Ukraine

Correspondence to: Dr Jorge André Cardoso

Ora Clinic, Rua 23, 344, 3 C, 4500-142 Espinho, Portugal; Tel: +351 916 121312; Email: jorge.andre@ora.pt

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Abstract an exclusively direct method to manage

these patients for whatever reasons, the
The treatment or management of tooth authors propose in this article a thought
wear with composite resins can be chal- process applied to diagnosis and treat-
lenging because significant alterations ment planning that allows the restoration
in the patient’s occlusion are usually of extensively worn dentitions in a logi-
required. Comprehensive approaches cal clinical sequence. The first goal is
include the use of facebows, articulator- to provide a clear and organized vision
mounted casts, laboratory-made wax- of the functional, biologic, and esthetic
ups, and silicone indexes to deliver the principles of treatment planning based
restorations. Even though this sequence on the most current, evidence-based no-
of steps is recommended, in many cases tions and clarified insights from experts.
it is not applied. The reason for this is re- These are principles that should be ap-
lated to the complexity and time required plied universally in any comprehensive
for these steps, which are normally ap- treatment plan. The second goal is to
plied in indirect restorations like ceram- propose the application of these prin-
ics but not properly used in direct com- ciples to direct restorations even when
posite resin rehabilitations. Moreover, a no individualized articulator mounting
large portion of these patients, clinicians, or appropriate laboratory wax-ups are
and technicians in many countries may available – the anatomically driven di-
not have the resources and/or tools to rect approach (ADA).
undertake a full comprehensive ap-
proach. In order to aid clinicians to use (Int J Esthet Dent 2018;13:16–48)

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Introduction parameters specific to wear cases that

can be especially helpful when a wax-up
Tooth wear results from mechanical is not available.
(abrasion, attrition, and abfraction) and
chemical (erosion) processes,1 quite
often acting in synergy.2 The incidence Clinical management
of people with pathological or acceler-
of generalized tooth wear
ated tooth wear is rising,3,4 and this in-
creased prevalence is even more evi- What was a few decades ago consid-
dent in young people,5,6 probably due ered a complex treatment is today sig-
to modern lifestyle behaviors such as nificantly clearer due to a better under-
frequent ingestion of acidic beverages, standing of adhesion and functional
stress-aggravated diseases like brux- occlusion. In the past, long-established
ism and gastric reflux, or psychological approaches would require extensive
disorders like bulimia.7 Therefore, the preparations, sometimes involving root
emphasis should be on early diagnosis canal treatments, to provide mechani-
to address the causes and prevent dis- cal retention for restorations with high in-
ease progression.8 trinsic strength such as porcelain fused
Dentin is more prone to erosive and to metal or porcelain fused to zirconia.
mechanical wear than enamel, thus the However, more recent research shows
consequences of tooth wear are worse that adhesive dentistry can provide ac-
on exposed dentin.9 A more or less con- ceptable clinical outcomes and limit the
sensual recommendation is to perform a ongoing wear process.15
restoration or dentin sealing as soon as #PUI
DFSBNJD
BOE
DPNQPTJUF
SFTJO

there is exposure.10-12 Traditional treat- materials have been applied in the mini-
ments that remove most of the remain- mally invasive treatment of tooth wear.
ing enamel with excessive tissue prep- Although composite resin materials pre-
aration for retention principles do not sent physical limitations in terms of co-
seem to favor the lifespan of the denti- hesive strength, oral degradation, and
tion. There is increasing evidence sup- color stability, they can provide an im-
porting minimally or noninvasive adhe- portant alternative to ceramics for many
sive approaches to worn dentitions.13-15 patients.18-20 Some authors consider
Several restorative strategies have been composite resin to be the material of first
described using a diagnostic wax-up to choice for posterior teeth as it provides
aid the clinician in the treatment strat- good clinical performance at a lower
egy. The use of direct approaches with- cost; is easier to fabricate and more pre-
out a wax-up has also been described; dictable to repair;21 causes less wear
however, they have been based on the on the opposing dentition compared to
empirical technical skill of the clinician ceramics;22 and may have load-absorb-
and do not rely on any one specific pro- ing properties when used from milled,
tocol.16,17 The present article describes highly polymerized computer-aided
a direct restorative strategy based on design/computer-aided manufacturing
anatomical, functional, and esthetic (CAD/CAM) materials.23,24 Although it

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a b c

d e f

g h i

Fig 1 Clinical case provisionally restored with noninvasive composite resin restorations following the ideal
workflow: comprehensive wax-up on articulated mounted casts using a facebow, and customized incisal
table based on original anterior guidance path. The wax-up was then transferred to the restorations using
one of the many available techniques – transparent silicone with individual matrixes according to the “index
technique” by Ammannato et al.31

is clear that ceramic restorations, espe- of worn dentitions with their description
cially monolithic glass ceramics such as of the three-step technique: occlusal
lithium disilicate, have high long-term plane, posterior support, and anterior
survival rates in posterior teeth, there is guidance. This approach combines di-
ongoing debate regarding the clinical verse scientific knowledge with logical
performance of composite resin versus clinical steps to offer a practical guide
ceramic due to the lack of consistent for treatment.
clinical trials.25,26
Since the rehabilitation of extensive
tooth wear frequently results in signifi- Anatomically driven direct
cant occlusal alterations, many of the
approach (ADA)
rules and guidelines that were once
strictly adhered to without proper scien- When using direct composite restor-
tific evidence are now being questioned ations, a comprehensive wax-up made
and replaced by more clinically oriented from articulated casts guided by effec-
and evidence-based approaches. Vailati tive clinician–technician communication
BOE
#FMTFS27-29 contributed significantly is always desirable (Fig 1). This can fa-
to this debate around the management cilitate diagnosis, optimize laboratory

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Inter- Occlusal Occlusal Tooth Gingival Posterior

maxillary vertical plane display and levels tooth
Relation & dimension Phonetics anatomy
Guidance (OVD)

Fig 2 The eight basic parameters that should be considered for diagnosis and treatment planning of
extensively worn dentitions: intermaxillary relation, mandibular guidance, occlusal vertical dimension, oc-
clusal plane, tooth display, phonetics, gingival levels, and posterior tooth anatomy.

communication, and provide a better parameters evaluated chairside with the

anatomy of the final restorations. Trans- patient.
ferring the anatomy created in the wax-
up into the mouth can be performed Diagnosis and treatment planning
using several techniques, including the
use of transparent vacuum-formed30 or A clear understanding of the critical
silicone matrixes31 applied to full-arch, parameters is important when plan-
quadrant sections or sequential single ning extensive restorative treatment ap-
teeth (Fig 1). proaches (Fig 2).
With the increasing number of wear
cases, a legitimate question can be Temporomandibular disorders (TMDs)
asked: In the case of a lack of laboratory A preliminary diagnosis regarding TMDs
resources, financial limitations or a clini- related to masticatory muscles or joints is
cian’s preferences, are there predictable mandatory. Muscular or joint pain should
treatment workflows and approaches be dealt with before any functional diag-
that allow for the restoration of these ex- nosis or treatment is performed.32 Mus-
tensive cases directly with composite cular function or hyperactivity problems
resin? With this question in mind, the au- will prevent the correct assessment of in-
thors suggest that whenever a compre- termaxillary relations. Temporomandibu-
hensive wax-up is not available, a direct lar joint problems that have not healed
approach can be adopted, based on or adapted properly may continue to
the anatomy of the remaining dentition cause pain and occlusal instability.33
as well as the esthetic and functional The history of an unstable bite (eg, as a

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result of a joint problem such as osteoar- an intermaxillary relation unless it pre-

thritis) is also a contraindication for any sents a difficult prosthetic, physiologic,
final restorative procedure.34 In case of or esthetic challenge. Since CR influ-
doubt, a referral to a TMD specialist is ences the OVD so directly, it is the most
highly advisable before any restorative significant parameter influencing the
treatment takes place. treatment plan. It is therefore manda-
tory to check it early in the examination.
Intermaxillary relation #FTJEFT
B
DPSSFDU
NBOVBM
NBOJQVMBUJPO

Although there is still debate about the complementary tools such as occlusal
clinical advantages of restoring patients jigs or splints may be used for short (or
into centric relation (CR), its use is tech- longer) periods, providing muscle de-
nically helpful as it provides a predict- programming so that a correct CR can
able rotation axis when all occlusal be determined.37,38
contacts are lost.35 Using the difference
from CR to maximum intercuspation (MI) Occlusal vertical dimension (OVD)
has the following important advantage: Compensatory eruption is usually pre-
the posterior rotation of the mandible sent in worn dentitions maintaining the
will, in many cases, provide the anterior OVD.39-41 Losses of OVD can only be
restorative space that is often lacking. suspected when: 1) posterior dental
This results in an increase of the occlusal support is lost (missing tooth pairs on
vertical dimension (OVD) while avoiding both sides), making it difficult for the
the stretching of the mandibular eleva- anterior teeth to support the vertical di-
tor muscles.36 However, in some cases, mension; or 2) when the wear is faster
the difference from CR to MI is so exten- than the compensatory eruption, which
sive that a non-physiologic anatomy of is always a subjective diagnosis.42 Al-
the restorations would be expected for though it may be interesting to know how
correct anterior guidance and support. much OVD has been lost, what is of real
For example, in large CR-MI slides, res- importance is knowing how much more
toring the patient in CR may result in will be needed for restorative, functional,
bulky palatal surfaces on the maxillary and esthetic purposes. The increase of
anterior teeth so that the mandibular in- OVD is dictated by the space needed
cisors can maintain contact. This situa- for a favorable overbite and overjet (both
tion will certainly impact on phonetics. around 2 to 4 mm43) on anterior restor-
Additionally, in some patients, this CR- ations. It is good to bear in mind when
MI difference can result in a retrusive planning treatment that increasing the
facial profile. More importantly, it can OVD and/or repositioning the mandible
promote an extensive retrusive mandib- into CR will reduce the overbite and in-
ular movement that may reduce airway crease the overjet, and vice versa.44,45
volume in the upper respiratory tract. Reasonable increases in OVD to cre-
This needs to be considered because it ate restorative space do not seem to
can, eventually, be important in patients cause TMDs and are considered safe
with obstructive sleep apnea. In sum- procedures.46,47 There are several tech-
mary, CR should be the first choice for niques for increasing the OVD, and it is

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Normal alveolar bone

Possible bone
remodelation
with teeth intrusion

Dense alveolar bone

Maximum ↑ OVD
Difficult bone
intercuspation (MI)
remodelation,
= Muscle
fractures and
Centric relation (CR) stretching
symptoms
more likely
Increased
muscular activity

Fig 3 Possible consequences of increasing the vertical dimension in patients where MI and CR coincide,
based on Dawson.36

Maximum Posterior mandibular No increased

intercuspation (MI) rotation to CR muscular activity,
≠ reduced risk
Centric relation (CR) ↑ OVD

Muscle
shortening

Fig 4 Consequences of increasing the vertical dimension in patients where CR is significantly different
from MI, based on Dawson.36

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trichion

30%
glabella

30%

subnasale ƃ Ƃ
stomion 45% 30%

40%
55% 70%
menton

Fig 5 Facial proportions based on soft tissue landmarks related to vertical dimension in females and
males according to modern anthropometric measurements.

the restorative need that should quan- due to increased bone density, the con-
tify the amount of increase.48 Two dif- sequences may be unpredictable, eg,
ferent philosophies regarding the ef- fractures, mobility, and muscular symp-
fects of increasing the OVD need to be toms (Fig 3). Increased bone density
considered: 1) That muscle adaptation may be suspected in severe bruxers
occurs for the new stretched position; with muscle hypertrophy, dense or scle-
2) That muscles do not adapt, and the rotic bone, enlarged alveolar processes,
same initial length will try to be main- and exostoses. However, these risks are
tained with increased muscle activity.42 minimized when there is a significant
If we consider that there is no muscu- difference between CR and MI. Relo-
lar adaptation, it means we assume that cating/rotating the mandible to CR will
the bone will remodel with the intrusion/ provide interdental space, especially in
extrusion of teeth as a consequence of the anterior region, without stretching
elevator muscle activity. Examples of the elevator muscles (Fig 4).36 In sum-
these phenomena include orthodontic mary, if a difference between CR and
movements, occlusal bite planes (such MI exists it can be used to relocate the
as the Dhal concept), and premature mandible and gain space without mus-
contacts. This remodulation is what cle stretching (Fig 4). If no MI-CR differ-
seems to happen in most cases when ence exists, then an increase of OVD
the OVD is increased (Fig 3).49 In a case will necessarily cause stretching of the
where bone remodeling is not possible elevator muscles. As these muscles try

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to return to their original positions, the effect on esthetics, as this is a major par-
consequences are usually not problem- ameter in facial and smile perception.
atic, since alveolar bone remodulation In some cases, the functional occlusal
will accommodate the intrusion of the plane does not match the visual percep-
teeth. However, in cases of increased tion of the plane and some corrections
bone density, these compensations will (that do not necessarily affect the palatal
not take place, therefore restorative fail- cusps or the functional occlusal plane)
ures and muscle symptoms are more may need to be performed on the buc-
likely to occur (Fig 3).36 cal cusps of the maxillary teeth to im-
Although there are several methods prove esthetics.
for accessing the vertical dimension, the
authors suggest using facial esthetic par- Tooth display
ameters as the primary method. There is There are several studies focusing on
a classic belief that the facial thirds are incisal edge display52,53 and anterior
of the same proportions; however, hu- tooth dimensions.54,55 Using average
man measurements show that the lower incisal edge display at rest as an ini-
third is about 10% longer than the mid- tial mock-up suggestion is an excellent
dle and upper thirds. There are also dif- starting point. Having a patient in a rest-
ferent proportions between the maxillary ed position is important. There are sev-
and mandibular areas on the lower facial eral methods to achieve this, the most
third according to gender50 (Fig 5). accurate (from the authors’ perspective)
is to first ensure that all facial muscles
Occlusal plane are tension-free, then ask the patient to
There are two important components to “open the mouth and drop the lower jaw
the occlusal plane: esthetics and func- without smiling.” This will provide a good
tion. The functional occlusal plane, which observation of not only the maxillary in-
is a simplified reference to the Curve of cisal edge position but also the mandib-
Spee, should allow the bilateral simulta- ular incisal edge display, as long as the
neous contact of teeth in their long axis. mandible is within a pure rotation axis
The esthetic occlusal plane should be without translation movements. Asking
in harmony (parallel) with the interpu- the patient to continuously say the let-
pillary line from the frontal view, but an ter ‘m’ and then stop will also result in a
asymmetric lip movement and chin may relaxed patient position.
further influence the position of the oc- For orientation purposes, the average
clusal plane from the frontal view. While maxillary incisal edge display is around
frontal view errors are usually detected 3 mm for females during their third dec-
early and corrected, lateral view errors ade of life. With aging, this is reduced
are unfortunately common. Establishing about 1 mm per decade. Comparative-
the esthetics of the occlusal plane from ly, males show 1 mm less than females
the lateral view, parallel to Camper’s for the same age group.53 Conversely,
Plane, is a critical step in dental reha- mandibular incisal edge display pro-
bilitations.51 According to the authors, gressively increases with age. During
these errors can have a very negative their 20s, the mandibular incisal edges

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of females have about the same vertical slightly touch the lower lip, and never go
position as the lower lip at rest, which beyond the wet zone.58 The next step
would be considered a 0-mm exposure. would be to test the ‘s’ sound which can
This exposure increases 1 mm per dec- be influenced by horizontal or vertical
ade. Males will show about 1 mm more volume alterations on the anterior teeth.
of their mandibular incisors than females Some patients pronounce ‘s’ with an
of the same age.52 The reason for these upward vertical movement of the man-
variations with age relate to the obvious dible, with the mandibular incisors be-
downward shift of facial tissue through- hind the maxillary ones.59 The speech
out life.56 Averages values often repre- of these patients is impaired mainly
sent a small sample of the population when the horizontal volume of the anter-
and should only be regarded as starting ior teeth is incorrect – upper palatal or
points to be integrated with the patient’s lower buccal. The most typical problem
facial dynamics, personality, and treat- is excessive volume on the palatal area
ment goals. A patient may, legitimately, of the maxillary incisors. In other pa-
want to look younger, and an increase tients, the ‘s’ sound is pronounced with
in maxillary tooth display for his or her a downward horizontal movement of the
age may be provided as long as it is es- mandible, placing the incisors edge to
thetically, functionally, and phonetically edge. These are less tolerant to vertical
viable. volume additions on the anterior teeth.60
Once the incisal edge display of the Additionally, ‘s’ sounds can be helpful to
central incisors has been established, test the OVD.61,62 If the posterior teeth
it is fairly easy to integrate the relative touch during the pronunciation of ‘s’, the
dimensions of the lateral incisors and OVD certainly needs to be reduced. The
canines.54,55 In terms of horizontal pos- patient should be allowed a few days
ition, a practical guideline is not to place for neuromuscular adaptation between
the incisal edges so that they invade the adjustments.
dry portion of the lower lip. The transition
from the wet to the dry area of the lower Gingival levels
lip is the most buccal limit for positioning The gingival levels provide clues for
maxillary central incisors.57 evaluating the wear pattern as they can
show compensatory eruption of worn
Phonetics teeth (Fig 6).63 When the gingival level
It is important to test the phonetic impli- is similar between the anterior and pos-
cations in extensive rehabilitations in an terior teeth, the wear has a generalized
objective manner. If speech impairment pattern. In cases where there is a dif-
is heard in a specific sound, the clinician ferential anteroposterior gingival level,
should be aware of the most common more compensatory eruption has oc-
changes needed. curred in the areas where the gingiva is
The first step is to test for the ‘f’ and ‘v’ more coronal.
sounds and provide adjustments. When Crown lengthening procedures may
the patient is making these sounds, be considered in cases of excessive gin-
the maxillary incisal edge should only gival display, as long as no root exposure

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a b

c d

Fig 6 Illustration of different types of tooth wear and their effects on teeth and gingival levels. (a) Unworn
dentition. (b) Generalized wear and compensatory eruption. (c) Anterior wear with anterior compensatory
eruption. (d) Posterior wear with posterior compensatory eruption.

occurs as a consequence. If the exces- of the anatomical crowns (measured from

sive soft tissue display is due only to the the cementoenamel junction), we can
occlusal movement of the gingival mar- calculate that premolar teeth have clin-
gin from the compensatory eruption as ical crowns that range from 7 to 8 mm,65
a response to wear, the amount of tissue and those of molars from 6 to 7 mm.66
that can be removed without resulting In addition to the clinical crown di-
in root exposure is limited. Moreover, mensions, it is important to have no-
restoring root-exposed dentin and ce- tions of posterior tooth anatomy, which
mentum areas with adhesive materials goes beyond the scope of this article.
may not be biomechanically stable in Special attention should be paid to the
the long term.64 interproximal contact points; their pres-
ence should be confirmed before start-
Posterior teeth guidelines – ing, and, when deficient, they should be
height dimensions anatomically reestablished.
In an ADA, it is important to consider the
usual shapes and dimensions of teeth. Mandibular guidance
The clinician should visualize the amount From a simplified perspective, the ana-
of tooth that has been worn in order to re- tomy and histology of human teeth seem
store the occlusal shape. Reducing the to indicate that anterior teeth are pre-
average size of the soft tissue coverage pared to receive horizontal forces, while

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Fig 7 Some degree of freedom from MI that allows mandibular incisors to close slightly forward without
causing horizontal forces on the maxillary anteriors (fremitus) is a well established and clinically relevant
concept.

posterior teeth have evolved to support guidance, and group function. Anter-
stronger vertical loads.67 In the widely ior guidance will, ideally, distribute the
accepted concept of mutually pro- loads during protrusive movements
tected occlusion, anterior teeth protect on all incisor teeth. In the initial path of
posterior teeth from horizontal forces movement all the incisors make con-
by disclusion in eccentric mandibular tact. As the mandible moves forward,
movements – mandibular guidance. these contacts become progressively
Also, posterior teeth provide most of exclusive of the central incisors, as they
the support from vertical forces, limiting are usually longer. One important fea-
the amount of stress on anterior teeth in ture to be incorporated in anterior teeth
MI. There seems to be consistent evi- is the ability of the mandible to close in
dence that this ‘ideal’ occlusion princi- a rested (and usually slightly forward)
ple is much more helpful in protecting position without causing any fremitus
the teeth themselves than in preventing – a horizontal shift or vibration of teeth
TMDs,68,69 muscular dysfunction70 or indicating instability (Fig 7).72 Fremitus
parafunctional activity,71 since the main on the anterior teeth indicates a lack of
etiologies of these are not occlusal. overjet in the MI occlusal stop in the cin-
From a generic point of view, guid- gulum of the maxillary teeth. It is also in
ance in eccentric movements can be line with ‘centric freedom’ or ‘long cen-
obtained with anterior guidance, canine tric’ concepts, which maintain stabilizing

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While the anterior guidance scheme

is more or less consensual, the deci-
sion about which lateral guidance to
choose for a specific patient requires
some flexibility.73 Canine guidance may
promote the complete absence of hori-
zontal loads in posterior teeth, is easy to
create and has been linked to reduced
muscular activity.75,76 Not only is it more
prevalent in Class  II occlusions (more
inclined occlusal plane), but also easier
to do in these patients than in Class  I
or III patients (more horizontal occlusal
Fig 8 Anterior guidance and group function oc-
clusal contacts achieved in clinical practice (left) plane).73 In group function, more com-
versus an ideal occlusal scheme (right). An ideal mon in older patients,74 contacts occur
occlusal scheme is more of a concept to work to- from the canine to the mesial cusp of the
wards rather than something precisely achievable
in clinical reality.
first molar during the initial part of move-
ment, while progressively being trans-
ferred anteriorly until only the canines
touch when reaching edge to edge.
contacts in the first 1 to 1.5 mm of move- It has been pointed out that canine
ment. This feature has been consistently guidance is the usual scheme to try to
considered in literature reviews on this implement first. This is especially true in
topic,72-74 and the authors believe it to orthodontic treatment, when no restor-
be an essential step that is often over- ations are to be performed.74 However,
looked in the adjustments of orthodontic canine guidance does not reduce ex-
and restorative treatments, causing re- cessive parafunctional activity in many
striction in mandibular movements and patients, and stress may be induced on
unnecessary stress on anterior teeth. the canines. In addition to tooth-related
Once MI stops are defined, this ‘cen- problems, this stress can cause fractures
tric freedom’ is easily accomplished in of the restorative materials. In cases with
protrusive movement by asking the pa- a natural functioning canine guidance
tient, in the upright position in the dental where a significant anterior-only attrition
chair, to continuously open and close is already seen, parafunctional activity is
the mouth, in a relaxed position but at suspected to continue. In these cases it
a fast pace. When the clinician applies is likely that group function will promote
very soft finger touch on the buccal sur- better load distribution on more fragile
face of the anterior teeth, those teeth in restorative materials.
stress will transmit an evident vibration. In addition to the above recommenda-
These contacts need to be identified, tions, it is important to state that occlusal
adjusted, and reviewed during subse- schemes are highly variable in nature,
quent appointments until the fremitus and patients usually adapt well to either
completely disappears. canine guidance or group function.77

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Table 1 Occlusal concepts to implement

#JMBUFSBM
TZNNFUSJDBM
DPOUBDUT
JO
BMM
UFFUI
MFTT
JOUFOTF

Maximum intercuspation (MI)
on anterior teeth

Discludes all posterior teeth during protrusive move-

Anterior guidance
ments

Discludes all posterior teeth during excursive move-

ments
Easier to implement
Canine guidance
More common in younger and Class II patients
Potential to reduce muscle activity in some patients
Higher stress on canine teeth
Lateral guidance
Progressively discludes posterior teeth during excur-
sions
More difficult to implement
Group function
More common in older and Class I and III patients
Potential to better distribute loads on several teeth and
therefore reduce stress on restorations

Provides some degree of movement from MI (centric

freedom) before any disclusion
Freedom in mandibular movement
Removes damaging horizontal forces on anterior teeth
with a relaxed mandibular closure

Since no clear advantages exist to select rigid occlusal

Patient comfort, simplicity, schemes, comfort, simplicity, and being minimally
and minimal invasiveness invasive or noninvasive are essential principles when
providing an occlusal scheme

From the authors’ perspective, it is ir- the avoidance of non-working side con-
rational to believe that absolute ideal tacts on restorations.48,77 Table 1 sum-
occlusal contacts can be achieved in marizes the essential occlusal concepts
patients, as this is a concept to work to- to implement.
wards rather than a clinical reality (Fig 8).
Instead of complicating treatment with Treatment sequence
strict occlusal schemes, it is preferable
to provide patient comfort; simplicity of There are many sequential approaches
treatment; less-invasive strategies; and when doing a full-mouth wax-up in the
a focus on generic, evidence-based laboratory. In most cases, the final pos-
guidelines such as posterior disclusion, ition of the maxillary incisal edge is de-
freedom in centric, load distribution, and termined at the start of the procedure,

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1 2

3 4

Fig 9 Treatment sequence according to the ADA: Stage 1: Mandibular teeth to establish a new functional
occlusal plane. Stage 2: Maxillary posterior teeth establishing the new vertical dimension. Stage 3: Anterior
guidance. Stage 4: Esthetics on the buccal areas of the maxillary teeth.

based on the mock-up or digital smile create an unworn anatomy on the res-
design provided by the clinician. Then, torations and then to remove it, where
all the remaining teeth are waxed. In a necessary.
direct approach, a different sequence „Considering the above principle, the
needs to be applied to provide a sys- palatal surface of maxillary anteriors
tematic, organized, and efficient use of can only be finished after the final ver-
time, whether the treatment is carried tical dimension and incisal edges of
out in one long or several shorter ap- the mandibular anteriors have been
pointments. A few points must be con- established. For the same reason, the
sidered in the promotion of a different esthetic layering of maxillary anteriors
approach: is only possible after the palatal sur-
„Trial-and-error composite resin place- face has been established.
ment should be avoided. Subtractive
changes of trial vertical dimensions With these specifications inherent to a
are easier to perform than additive full-mouth ADA, the most efficient treat-
changes, for obvious reasons. So ment sequence, according to the au-
the principle for a direct approach thors, is performed in five stages (Fig 9;
is always to add composite resin to Table 2):

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Table 2 ADA treatment sequence

Stage Main goal Procedures

Evaluate difference from CR to MI; identify wear pattern;

Stage 0 Diagnosis and planning
observe tooth display and gingival levels

Restore the mandibular teeth to establish a new functional

occlusal plane

Stage 1 Functional occlusal plane Mandibular incisal edge display can be used as a starting
reference point

The patient is left with a provisional vertical dimension

Restore the maxillary posterior teeth and perform the occlus-

Stage 2 Vertical dimension al adjustments from a functional perspective, establishing
the final vertical dimension with static occlusal contacts

Construct and adjust the palatal surfaces of maxillary an-

Stage 3 Guidance teriors for a correct anterior guidance with posterior tooth
disclusion

A direct mock-up of the maxillary incisal edges provides a

perspective of the new occlusal plane, tooth display, and
phonetics
Stage 4 Esthetics and phonetics
Adjustments are made if needed

Using a modified silicone matrix made from the mock-up,

incisal edges and maxillary buccal areas are finally restored

„Stage 0: Diagnosis and planning – It is also important to think about the dif-
evaluate critical aspects such as CR- ferent wear patterns since they require
MI slide, wear pattern, and incisal some specific considerations.
edge position.
„Stage 1: Functional occlusal plane – Generalized wear
restore mandibular teeth to establish A generalized wear pattern can be
a new functional occlusal plane. identified by a flattened occlusal plane
„Stage 2: Vertical dimension – restore and Curve of Spee (Figs 6 and 10). In
maxillary posterior teeth, establishing Stage 1, all the mandibular teeth should
the new vertical dimension. be raised to what is thought to be the
„Stage 3: Guidance – restore palatal most adequate anatomy. To do so, the
surfaces of maxillary anteriors and mandibular incisal display should be
mandibular guidance. taken into account. After the Stage 1
„Stage 4: Esthetic and phonetics – direct restorations, if an excessive dis-
perform a mock-up, test for phonet- play is observed, adjustments should be
ics, and restore the incisal and buccal made to create a new occlusal plane.
areas of the maxillary teeth. If the next stage is to be performed at

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a b c

Fig 10 Examples of generalized wear (a), anterior wear (b), and posterior wear (c).

the next appointment, at least one tooth accordingly. In most cases, these palatal
from each side should have simultan- restorations are performed over intact,
eous contacts for mandibular stability at non-worn, palatal enamel to provide new
this new provisional vertical dimension. static contacts with the mandibular teeth.
To achieve this, the clinician may need During Stage 4, the buccal esthetic
to add a provisional restoration on a sin- parameters of the maxillary teeth are
gle maxillary tooth. It is also important established and phonetics tested. A
that the next stage is performed within a mock-up will allow for the testing of
few days to minimize the risk of fractures tooth display and any interference in
and patient discomfort. speech. If critical phonetic problems are
During Stage 2, the maxillary teeth are present, it is important to correct them
restored to create a functional occlusal at this stage with the necessary sub-
plane and new vertical dimension. To tractive adjustments. Patients will usu-
do this, restorations are initially applied ally overcome minor speech problems
on the molars and bicuspids, providing within a few days. In case of doubt, it
the lost anatomy on these teeth on both makes more sense to finalize the restor-
sides. Rubber dam is then removed and ations and reevaluate. Any subtractive
the occlusion adjusted. The occlusal adjustments can always be performed
adjustment in this phase will provide a later on.
vertical dimension that is close to final. This final stage will integrate the fi-
Adjustment must accomplish bilateral nal esthetic parameters, especially in-
simultaneous contacts on all the poster- cisal edge positions, with the anatomy
ior teeth, leaving a minimum of 2 mm of previously created in the palatal areas
space in the anterior region for the maxil- (Fig 11). A smooth transition from inter-
lary palatal restorations while providing cuspation contact, guidance path, and
esthetically acceptable facial propor- incisal edge should be provided. The fol-
tions (Fig 9). lowing steps allow the clinician to create
During Stage 3, with bilateral con- this functional–esthetic harmony in the
tacts and a stabilized mandibular pos- anterior guidance (Fig 11):
ition, the palatal surface of the anterior „A direct esthetic mock-up is made to
maxillary teeth are restored and adjusted establish the desired incisal edge.

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a b

c d

Fig 11 Details of the final stage. (a) Situation at the end of Stage 3, with composite resin on the palatal
surfaces of the maxillary anteriors. (b) An esthetic mock-up is performed and a silicone matrix is con-
structed to capture the incisal position. (c) The silicone matrix is adjusted with a bur to smoothen the tran-
sition between the palatal anatomy and the new incisal edge. (d) Part of the previous palatal restoration
is removed, and final restorations are performed with the adjusted silicone matrix. A small palatal chamfer
with which the new material can engage will probably improve retention.

„A silicone matrix is constructed with incisal anatomy of the final esthet-
this direct mock-up to capture the ic restorations. Part of the previous
incisal position in order to guide the palatal restoration may need to be
final restorations as well as the previ- removed for esthetic layering. In this
ously created palatal anatomy. case, overall retention will probably
„The silicone matrix is adjusted with be improved by a small palatal cham-
a bur to smoothen the transition be- fer with which the new restorative ma-
tween the palatal anatomy created terial can engage.78
in Stage 3 with the new incisal edge
position to be created in Stage 4. It Once all areas are restored, small chang-
is important to leave the incisal edge es and adjustments may be needed. If
with at least 1-mm thickness, as ex- so, it is usually simple to provide further
plained later in the discussion. adjustments without the need for addi-
„The customized silicone matrix will tive composite resin, which is an essen-
then serve to guide the palatal and tial premise of the concept.

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Anterior wear be restored, to provide posterior stabil-

A very common situation is anterior wear ity (Stage 2). Once the posterior teeth
with unworn posterior teeth (Figs 6 and and palatal surfaces are restored on the
10). In these cases, the anterior teeth maxillary teeth, Stages 3 and 4 (anterior
usually undergo compensatory eruption, guidance and esthetics) are performed
showing more coronal gingival levels as for generalized wear, as previously
relative to the posterior teeth. The treat- mentioned.
ment of choice should be orthodontic
intrusion on the over-erupted segment, Posterior wear
which places the gingival level at its cor- Wear cases limited to posterior teeth
rect position, followed by restorations. (far less common) are highly challeng-
This is the best approach because un- ing (Figs 6 and 10). Attrition wear exclu-
worn posterior teeth indicate that there is sive of the posterior teeth occurs when
no loss of vertical dimension; therefore, anterior teeth do not contact, eg, open
restoration of the posterior teeth could bites and Class II or III with severe over-
be avoided. bites and overjets. In these cases, any
If no orthodontic treatment is per- approach that does not include ortho-
formed, all mandibular teeth may need dontics should be seen as a temporary
to be restored, the OVD raised, and a resolution.
new occlusal plane established. If there One option would be to restore the
is a significant difference from CR to MI, posterior teeth, leaving the same dys-
this will make the case easier because functional anterior guidance and main-
anterior space is automatically created taining the same occlusal scheme. If a
and fewer posterior teeth will need to be correct anterior guidance is attempted,
restored. The amount of additive mater- the same treatment sequence used for
ial in the mandible (Stage 1) is limited by generalized wear can be applied. How-
the maximum display of the mandibular ever, only a minimum amount of poster-
incisors to be esthetically acceptable. ior restorative volume is recommended,
In cases of anterior wear, the vertical otherwise the anterior space may be-
dimension is assessed before additive come excessive and a correct anterior
restorations are performed on the maxil- guidance would be impossible to pro-
lary teeth (Stage 2). This is because any vide. Therefore, these patients should
additional volume on unworn posterior be monitored closely for repairs, since
teeth should be limited, since they do reduced composite resin thicknesses
not actually need restorative protection. can be highly prone to further wear and
So, before proceeding to Stage 2, ad- fracture due to the absence of anterior
justments are made in the mandibular guidance.
posterior restorations until the patient Exclusive posterior wear also occurs
has about 2 mm of anterior space for a in cases with a significant difference be-
final corrected overbite and overjet (both tween CR and MI, combined with grind-
around 2 to 4 mm). After this, only the ing only in CR. Contrary to horizontal
maxillary posterior teeth that do not con- movements in the anterior wear pattern,
tact at this new vertical dimension will these patients grind their teeth within the

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Fig 13 Initial situation: smile. Teeth seem to have

worn around 20% to 30% of their initial length. Com-
pensatory eruption also seems to have occurred.

Fig 12 Initial situation: portrait. Fig 14 Initial situation: intraoral view.

limited posterior area of the first contacts acceptable anterior guidance without
around CR. The grinding usually occurs overbulking the palatal surfaces of the
during the night, with a retruded man- maxillary anterior teeth.
dible. During the day, the mandible ad-
vances, finding a more stable position
with more contacts in MI. This explains Case presentation
why these patients have anterior con-
tacts but wear is only seen in the pos- A 21-year-old female presented with
terior teeth. The ideal treatment would complaints about her smile and gener-
be orthodontic intrusion of over-erupted alized teeth hypersensitivity (Figs 12 to
posterior teeth (which usually requires 16). She said she displayed nervous bu-
efficient skeletal anchorage devices),79 limia behavior on average twice a week,
and restoration of the lost posterior or whenever she was particularly anx-
structure. An alternative to the ortho- ious. She had been in psychotherapy
dontic solution is to restore these cases for the past year and attended regular
as previously described for generalized psychiatry, psychology, and gastroen-
wear cases. As mentioned, if the centric terology appointments.
slide is extensive it may be preferable Clinical examination revealed gener-
to use MI instead of CR to provide an alized loss of tooth structure, including

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Fig 15 Initial situation: detailed view of worn maxillary dentition. Clinical history revealed that acid erosion
due to bulimic behavior, aggravated by parafunctional attrition and abrasion from aggressive toothbrush-
ing, were the most likely etiologic factors.

Fig 16 Maxillary and mandibular occlusal views. Palatal surfaces of the anterior maxillary teeth and oc-
clusal surfaces were the most affected areas.

dentin, involving all the teeth, with mini- surfaces of the maxillary teeth and the
mum wear on the mandibular anterior occlusal surface of the maxillary mo-
teeth. The maxillary anterior teeth con- lars.14 Tooth 25 was missing.
GPSNFE
UP
B
7BJMBUJ#FMTFS27-29 Class  V No TMDs were diagnosed, nor was
erosion classification: a loss of more there a significant difference between
than 2 mm of incisal edge, extensively CR and MI. The periodontal parameters
exposed dentin and enamel loss on the were normal, with a good oral hygiene.
palatal areas, and distinctively reduced There were obvious esthetic conse-
facial enamel (Figs 14 to 16). The tooth quences, such as short and discrete
wear pattern confirmed the etiology of teeth, and secondary eruption causing
acid erosion combined with parafunc- a slightly excessive gingival display.
tional activity, mainly affecting the palatal

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Treatment plan discussion

Due to the extent of the tooth structure

loss, only conservative approaches with
minimal or no tooth preparation were rec-
ommended to the patient. Although ce-
ramic restorations were presented as the
best long-term solution, the final decision
was to use composite resins, for financial
reasons. Moreover, it also made sense to
gain time to evaluate the bulimic disorder
progression. This type of case demands
the use of some sort of restorative solu-
Fig 17 Stage 1: In the initial stage, the mandibu-
tion, otherwise further worsening of the lar posterior teeth are restored up to their supposed
condition is likely to occur. original anatomy.
It is difficult to determine if the OVD
was lost in this case. Although the pos-
terior teeth were worn, there seemed to
be a degree of compensatory eruption.
Despite this, the treatment would have
to provide an increased vertical dimen-
sion, since no space could be created
with a CR-MI difference.
This case was approached accord-
ing to the guidelines described for a
generalized wear case. The mandibular Fig 18 Stage 1: The mandibular teeth from the
first premolar to the first molar on each quadrant
occlusal plane indicated an overerup-
are restored. After rubber dam removal, the patient
tion of the anterior teeth. The cause for is left with a least one occlusal contact on each side
this is related to the Class  II division  2 at this provisional vertical dimension.

occlusal pattern. The erosion of the

palatal surfaces of the maxillary anter-
ior teeth may also have played a role in An implant with a provisional crown
this. The maxillary occlusal plane was was planned to replace missing tooth
flattened, with generalized wear. There- 25. The implant-supported provisional
fore, it was planned to correct the man- crown allows time for the evaluation of
dibular occlusal plane, increasing the the clinical performance of the compos-
posterior teeth and leaving the anteriors ite resin restorations before a definitive
untouched. Once that was performed, ceramic crown is delivered.
the maxillary posterior teeth would be
restored, increasing the vertical dimen- Treatment
sion. And finally, the anterior guidance
and maxillary buccal esthetics would be In the first appointment, all the posterior
addressed. mandibular teeth from the first premolar

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A second appointment was planned

for the direct reconstruction of the oc-
clusal surfaces of the maxillary poster-
ior teeth from the first premolar to the
first molar (Fig 16). Once the occlusal
contacts were adjusted, the new vertical
dimension was established.
During the third appointment, all
Fig 19 Stage 2: At the second appointment, the
the maxillary anterior palatal surfaces
direct reconstruction of the occlusal surfaces of the
maxillary posterior teeth to their original anatomy is
were reconstructed, with the new anter-
done. Occlusal adjustments are then performed to ior guidance with posterior disclusion
create a stable static occlusion at this new vertical (Figs 17 and 18).
dimension.
In the fourth appointment, the maxil-
lary anterior gingivectomy and impres-
sions for home bleaching with 10% car-
bamide were performed, since all the
dentin was now protected. Two weeks
after the bleaching process, a mock-up
of the maxillary anterior teeth was per-
formed directly in the mouth. The direct
mock-up basically previews the buccal
anatomy and incisal edges (Fig 19). A
silicone matrix was made to record the
desired incisal length on the mock-up.
During the final sessions, all the buc-
cal surfaces and incisal edges of the
Fig 20 Stage 3: Palatal surfaces of the maxillary
anterior teeth were layered with the aid
anterior teeth are restored to provide contacts at the
vertical dimension created in the previous stage. of the silicone matrix, providing an es-
thetic occlusal plane. In order to smooth
the transition from the palatal composite
resin created in the previous stage and
to the first molar in each quadrant were the final incisal edge based on the mock-
restored with a microhybrid direct com- up, the silicone matrix needed to be ad-
posite resin, based on their lost anatomy justed with a carbide bur (Figs 8, 20, and
(Figs 14 and 15). There was no tooth 21). In this way, the final anterior restor-
preparation, only the direct application ations preserve the occlusal contacts
of the material. The mandibular incisors in MI and the functional path of the an-
were not restored as they were over- terior guidance, while adopting the new
erupted due to the increased overjet. incisal edge tested in the mock-up. The
At this stage, the patient was left with a palatal composite resin can be partially
transitory vertical dimension, where pro- removed to help in the layering process.
visional tooth contacts should provide Occlusal adjustments were carefully
mandibular stability. made to provide posterior disclusion in

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Fig 21 Stage 3: At the end of this stage, both static occlusion and anterior guidance have been created
for the patient. The anterior guidance is adjusted to provide posterior teeth disclusion. From the buccal view,
one can see that the transition between the palatal restoration and the buccal surface is still unrestored.

a b

Fig 22 Stage 4: Esthetic direct mock-up to evaluate final incisal edge position. Incisal display at rest ac-
cording to age and lip movement will determine the most natural position for each patient.

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all mandibular movements (Fig 19). The

primary anatomy, contours and line an-
gles, initial polishing, secondary anato-
my (macro and micro-texture), and refin-
ing polishing were distributed over two
appointments (Fig 20). The final results
were very satisfactory for the patient
(Figs 21 to 25).

Fig 23 The silicone matrix, previously custom-

ized with the direct mock-up, serves to guide the Discussion
final esthetic restorations.
In this clinical case, a good esthetic re-
sult was achieved with direct composite
resin restorations (Figs 26 to 31). Since
bulimia is a disorder with a strong psy-
chological component, a complete cure
is difficult to achieve; therefore, higher
maintenance is necessary. This should
be explained to the patient.
The traditional wax-up approach is
undoubtedly the most strongly recom-
NFOEFE
TUSBUFHZ
#FJOH
BCMF
UP
QFSGPSN

try-ins can certainly prevent problems
and help the dental team to visualize the
Fig 24 After the palatal and incisal anatomy are
established in the palatal shell, the resin stratifica-
final result. This is especially true in com-
tion is performed. prehensive interdisciplinary cases com-
bining wax-ups and orthodontic setups.
The present article, however, is focused
on the direct, noninvasive reestablish-
ment of function and esthetics of a worn
dentition. Although this is not a new con-
cept,16,17 the proposed step-by-step
thought process – based on consistent,
evidence-based principles – clarifies
essential steps and guides the clinician
to achieve a predictable result.
The proposed method does present
disadvantages compared to a wax-up-
based strategy, these being the clini-
Fig 25 Final occlusal adjustment should provide
cian’s technical limitations, longer ap-
centric stops on all teeth (stronger on posteriors)
and an anterior guidance that provides posterior pointments, and a suboptimal occlusal
disclusion. definition (Table 3). However, when a

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Table 3 Different techniques for restoring worn dentitions

Wax-up-based Wax-up-based Direct treatment

direct restorations indirect restorations without wax-up (ADA)

A detailed anatomical, func-

tional and esthetic clinical
Treatment planning is facilitated with mounted
Treatment evaluation needs to be per-
casts since there is a better visualization of avail-
planning formed before starting the re-
able space and distribution of restorative volumes
storative stage because there
is no try-in of the wax-up

Direct restoration of the man-

Wax-up is made based on clinical indications, usu-
Starting dibular arch using the man-
ally using the desired maxillary incisal edge display
point dibular incisal edge display
as a reference
as a reference

In order to provide a logical

and optimized workflow, the
The wax-up is tested in the mouth through a principle is that compos-
mock-up with silicone indexes before initiating the ite resin is added until the
Possibility of rehabilitation desired anatomy and then
corrections
#PUI
BEEJUJWF
BOE
TVCUSBDUJWF
DIBOHFT
DBO
CF
reduced to accommodate oc-
made by the clinician or dental technician clusal limitations; therefore, no
additive changes are usually
needed

Knowledge of anatomy, and

Technical Ability to work with articulators, a facebow, impres-
the ability to sculpt and stratify
demand sions, and eventually preparations
composite resins

Occlusal
Potentially higher Potentially lower
precision

Minimally invasive or Depends on the prepar- Minimally invasive or non-

Invasiveness
noninvasive ation design invasive

Depends on the wax-

Esthetic Depends on the clinical ap-
up quality and clinical Highest with ceramics
outcome plication
application

More prone to fractures More prone to fractures and

and staining Highest longevity and staining
Longevity
High maintenance stability with ceramics High maintenance require-
requirement ment

Costs Higher laboratory fees Highest laboratory fees Higher chair time fees

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learnt from recent literature may be that

occlusal and functional parameters are
not improved in complete dentures when
a facebow articulation is used. Also, in
practical terms, every extensive reha-
bilitation (fixed or removable) can be
esthetically tested and readjusted in the
patient’s mouth without the need for the
previous facebow mounting of casts.
However, it is incorrect to believe that
Fig 26 Silver powder can be very helpful to es-
facebow articulation will not save clinic-
tablish a natural texture according to the patient’s
age as well as provide natural asymmetries in sizes, al time by improving the communication
shapes, and rotations. with the technician regarding esthetics,
especially the orientation of the occlusal
plane. With these two important insights
in mind, we can also assume that using a
wax-up is performed, several visits are direct approach in extensive wear cases
mandatory (eg, mock-up or digital smile can potentially achieve a similar func-
design, facebow registration, intermax- tional quality to indirect or wax-up-based
illary records, and wax-up try-in). An strategies. However, this is not to say that
important advantage of the direct tech- wax-ups on facebow-mounted articulat-
nique is the possibility of doing a com- ed casts will not optimize the process,
plete rehabilitation without the need for because they do help significantly.
any laboratory steps. While chair time In the wax-up-based indirect strategy,
is regarded as the most significant cost the maxillary arch is first transformed
in more-developed western countries, into the desired shape based on the
it is important to realize that in many mock-up. Then, the mandibular teeth
countries the laboratory costs are actu- are adapted to the transformed maxil-
ally more impactful. Additionally, many lary teeth for a correct vertical dimen-
clinicians do not have access to dental sion, overjet, and overbite. This is the
technicians who are capable of perform- traditional planning approach in com-
ing comprehensive wax-ups. plete dentures and even in orthognathic
An interesting debate was raised re- surgery. It is critical to understand this
garding the real need for facebow reg- notion, since it provides a mental aid to
istration in the fabrication of complete plan extensive cases with indirect restor-
dentures, with increasing evidence of ations – the maxilla guides the esthetics
its clinical irrelevance.80-83 A facebow and then the mandible will adapt, when-
serves two purposes: 1) to provide a ever possible, providing the function.
more or less accurate rotation axis of However, in the direct approach pro-
mandibular closure, potentially improv- posed in this article, the mandibular arch
ing occlusal accuracy; and 2) to help in is established first, leaving the esthetics
the spatial orientation of the maxillary cast for the final steps. This is the exact op-
for esthetic purposes. The main lesson posite of an indirect wax-up strategy. As

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Fig 27 Final result: smile frontal view. Fig 28 Final result: smile lateral view.

Fig 29 Final result: intraoral view of maxillary anteriors.

Fig 30 Occlusal view at 2 years showing some wear and small areas of chipping, common in extensive
restorations with composite resin. An implant with a provisional restoration was placed on tooth 25.

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Mechanical limitations in composite

resins make these restorations suscep-
tible to fractures, and they require high
maintenance.85 In fact, both polishing
and small repairs should be expected in
the esthetic zones during the first 3 to 5
years.86 It is a common assumption that
the same incisal thickness should be
provided in the composite material as
the original volume of the intact, unworn
tooth. Although this can be recommend-
able with ceramic veneers, from the au-
thor’s experience it is not advisable with
DPNQPTJUF
SFTJOT
#POEFE
GFMETQBUIJD

ceramic, for example, has an elastic
modulus similar to enamel,87 while that
of composite resin is much lower.88 This
makes it susceptible to fractures, espe-
cially when applied in extensive restor-
ations. To increase its cohesive fracture
resistance, the authors recommend as
large a volume as possible of composite
Fig 31 Final result: portrait view.
resin in the incisal edge, within the obvi-
ous esthetic limitations (at least 1 mm).
Understanding broad functional par-
mentioned previously, the main reason ameters and biomechanics of tooth
for this is that the anterior maxillary res- wear is more important than blindly fol-
torations cannot be completed without lowing any specific advocated tech-
a correct establishment of the final pos- nique or material. A comprehensive,
ition of the mandibular incisal edges. well-planned approach will optimize
A common misconception is the po- time and results with most techniques.
tential negative effect of the patient be- In cases of attrition wear, occlusal splints
ing left with unstable occlusion between should always be used once the restora-
appointments due to the sequential ap- tive phase is concluded. Even though
proach. In case this happens, a mini- the use of splints has low patient compli-
mum time between each treatment stage ance if no TMD symptoms are present,89
should be planned – never more than a they should nevertheless be provided.
few days. However, in cases of increased Information regarding specific etiology
vertical dimension, where the mandible of wear is of paramount importance in
is left stable with bilateral simultaneous trying to improve patient collaboration
contacts, there is usually no concern.49 and behavioral change, when needed.90
This is, for example, a common situation Patients should also be informed about
during orthodontic treatments.84 possible contingency plans in case of

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treatment failure. Nevertheless, these occlusal principles. The use of virtual

restorations are easy to repair,4 biologic CAD wax-ups91 is likely to increase in
complications are rare, and the level of the future. In this sense, it is also impor-
patient satisfaction is high.85 tant for clinicians to diagnose and per-
From a conceptual point of view, one form treatment planning for extensive
needs to consider that a laboratory wax- cases based on what is examined with
up is made using the same principles the patient chairside.
outlined in this article, the only differ- Even though the described direct
ence being the capacity for trial-and-er- technique does present some challeng-
ror corrections with both subtractive and es, it can be a good alternative for many
additive changes in the wax. This can clinicians to provide extensive rehabili-
also be performed in the mouth, as long tations that would otherwise not likely be
as the additive changes are reduced performed.
or eliminated. This means the clinician
needs to provide an intact anatomy with
composite resin and then reduce for a Acknowledgments
correct visual and functional integra-
tion. The process is certainly achieva- Figures 2 to 4 and 6 to 11 were designed
ble when the clinician has the necessary using elements from Perfect Tooth soft-
knowledge of esthetic, anatomical, and ware (eHuman).

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